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Sample Hospital Immunization Policy

Sample Hospital Immunization Policy

The following sample immunization policy for active, courtesy, and associate house staff and clinical fellows, developed and approved by the Medical Board of The Johns Hopkins Hospital, was provided by Jay Frerotte, manager of safety administration, Johns Hopkins Medical Institutions. The sample policy may be used by health care facilities to help develop immunization policies for new appointees to the medical staff and for current hospital staff.

IMMUNIZATION POLICY FOR ACTIVE, COURTESY, AND ASSOCIATE HOUSE STAFF AND CLINICAL FELLOWS

PURPOSE

To reduce the risk of hospital personnel acting as vectors of disease to patients, and to provide a service to the individual staff member, these policies have been established.

POLICY

New appointees to the medical staff -

  1. All members of the medical staff must present acceptable documentation of immunity status or submit to testing of immunity status within 90 days of the effective date of their medical staff appointment. Applicants must complete testing through Occupational Health Services for immunity to rubella, rubeola, varicella, and in some cases hepatitis B (see below). In addition, an intermediate strength PPD will be placed and read provided there are not contraindications.
  2. Rubeola: Determination of immunity and requirement for immunization for rubeola will be according to the following table:

Individuals Born Before 1957

These individuals have a high likelihood of natural immunity from contracting the disease in childhood, before immunizations were developed and widely available. The likelihood of natural immunity is highest in people who know they have had measles as a child. Therefore, antibody testing and/or immunization will be voluntary for individuals in this age group and may be arranged through Occupational Health Services. Nevertheless, antibody testing may be required of these individuals in the event of an outbreak of measles.

Individuals Born In and After 1957

All individuals in this age group will have antibodies against rubeola measured.

Antibody titers positive: No vaccinations.

Antibody titers low positive: One vaccination, and the invitation to participate in a study through the Microbiology Laboratory to assess response with another blood sample 3-6 months later.

Antibody titers negative: Two vaccinations required, separated by 90 days, and the invitation to participate in a study through the Microbiology Laboratory to assess response, with another blood sample 3-6 months after the second vaccination.

For individuals whose tests reveal that they are not immune to rubeola, vaccination must be initiated within 3 months of the effective date of their medical staff appointment unless contraindications exist as determined by the Occupational Health Service.

    • 3. Rubella: All individuals will be assessed for immunity against rubella. For those with low positive or negative titers, immunization for rubella will be optional. Immunization for rubella will be according to the following table:
      • Antibody titers positive: No vaccinations.
      • Antibody titers low positive: One vaccination recommended and the invitation to participate in a study through the Microbiology Laboratory to assess response, with another blood sample 3-6 months later.
      • Antibody titers negative: Two vaccinations recommended, separated by 90 days, and the invitation to participate in a study through the Microbiology Laboratory to assess response, with another blood sample 3-6 months after the second vaccination.
    • 4. Hepatitis B: In the case of hepatitis B, antibodies will be measured only if there is a previous history of hepatitis B or immunization against hepatitis B. If immunity is not confirmed for these screened individuals, they will be offered the opportunity for immunization against hepatitis B. Those who give a history of previously completing a three-part immunization will be offered one "booster injection," while those who thought they had previously contracted hepatitis B, but are antibody-negative (bringing into doubt the correct diagnosis) will be offered the three-part immunization for hepatitis B. The remainder of the staff, who give no history of previous hepatitis B or immunization for hepatitis B, will be offered the three-part immunization for hepatitis B without being screened for antibodies beforehand. In no case, however, will hepatitis B immunity or vaccination be required in order to be granted privileges. In other words, immunization for hepatitis B is optional, not mandatory. Nevertheless, any individual who is not immune based on antibody testing and chooses not to be vaccinated must sign a statement indicating refusal.
    • 5. Tuberculosis: For those whose PPD is found to be positive, a chest X-ray within 3 months and referral to a physician for assessment and clearance will be required before final staff privileges can be granted. For those individuals with previous history of positive PPD, the report of a chest X-ray taken after the finding of positive PPD which indicates no evidence of active tuberculosis must be provided. Thereafter, no further evaluation is required in the absence of symptoms of tuberculosis.
    • 6. Varicella: All individuals will be assessed for immunity against varicella zoster virus (VZV).

    Antibody titers negative: Immunization is required.

    Vaccine will be offered free of charge and administered except if medically contraindicated. The names of those individuals unable to be vaccinated will be transmitted by Occupational Health Services to Infection Control and Epidemiology of the Johns Hopkins Hospital to be kept on file in case of an exposure. Those medical staff members who do not begin the vaccination schedule or receive a medical exception within 90 days of appointment will have their privileges suspended until they meet this requirement.

    Current hospital staff -

    • All current appointees will go through the procedures listed above for "New Hires" at the time of their next reappointment for staff privileges, except for varicella immunization. Thereafter, individuals without contraindications or previously positive PPDs will be required to have yearly PPDs, though certain divisions may require more frequent testing unrelated to credentialling (e.g., those employed in the Microbacteriology Laboratory). For those individuals who convert from PPD negative to positive, referral to a physician will be required. That physician visit could be arranged through Occupational Health Services or by the individual, but the reports of an assessment from a physician outside of Occupational Health Services must be reviewed by Occupational Health Services before staff privileges are renewed. Immunity to hepatitis B may be determined as often as every four years, if desired by the staff member, but it is not required. Subsequent testing for rubella, rubeola, and varicella will not be required.